RC EXAMINATION

REVIEW
Ahmad Alabdulqader
Waleed Alwadai
Khalid Alsudiry

01
HUMIDITY and
AEROSOL
 HUMIDITY THERAPY
What is the humidity?

Humidity is the quantity of moisture in air or gas that is caused by the addition of water in a gaseous state (vapor).
It is also referred to as molecular water or invisible moisture.

The objective of humidity therapy

Is to make up for water loss that occurs when dry gas, more than 4 L/min, is delivered or when the upper airway is bypassed.
Prolonged inhalation of dry gas may damage the epithelial layer of the airway, reduce ciliary activity, and increase the production of
thick mucus due to dehydration.

Clinical Uses of Humidity

1. To humidify dry therapeutic gases when flow is greater than 4 L/min.

2. To provide 100% body humidity of the inspired gas for patients with endotracheal (ET) tubes or tracheostomy tubes.

Normal Airway Humidification

1. The nose warms, humidifies, and filters inspired air.

2. The pharynx, trachea, and bronchial tree also warm, humidify, and filter inspired air.

3. By the time inspired air reaches the oropharynx, it has been warmed to approximately 34° C and is
80% to 90% saturated with water.

4. By the time the inspired air reaches the carina, it has been warmed to body temperature (37° C)
and is 100% saturated.

5. When the inspired air is fully saturated (100%) at 37° C, it holds 44 mg H2O per liter of gas and
exerts a water vapor pressure of 47 mmHg.
Absolute and Relative Humidity

Absolute humidity is the amount of water in a given volume of gas; its

measurement is expressed in milligrams per liter.
Absolute humidity = Relative humidity x Capacity
Relative humidity is a ratio between the amount of water in a given volume of
gas and the maximum amount it is capable of holding at that temperature
(capacity). Its measurement is expressed as a percentage.
Relative humidity = Absolute humidity / Capacity x 100

Examples
Example: A gas at 22° C has a relative humidity of 54%. Calculate the absolute
humidity. (Note: At 22° C, air can hold 19.42 mg H2O per liter.)
Absolute humidity = Relative humidity x Capacity
Absolute humidity = 0.54 X 19.42 mg/L = 10.5 mg/L

Example: The amount of moisture in a given volume of gas at 31° C is 24 mg H2O per liter of gas.
Calculate the relative humidity. (Note: At 31° C, air can hold 32.01 mg H2O per liter.)
Relative humidity = Absolute humidity / Capacity x 100
Relative humidity = 24 mg/L / 32.01 mg/L = 0.75 x 100 = 75%
 Body humidity
Body humidity is the relative humidity at body temperature and is expressed as a percentage.

Body humidity = absolute humidity / 44 mg/L x 100

44 mg/L The capacity of water at body temperature.

Example:
If the gas that the patient is inspiring contains 21 mg of H2O per liter of gas, what is the body humidity?

Body humidity = 21 mg/L / 44 mg/L = 0.48 x 100 = 48%

A 48% body humidity indicates that the inspired air is holding only 48% of the water it takes to fully
saturate the gas in the airway at body temperature.

The body’s humidification system adds the other 52% by the time the air reaches the carina.

Humidity Deficit
Inspired air that is not fully saturated at body temperature creates a humidity deficit.
Humidity deficit may be expressed in milligrams per liter or as a percentage.
Humidity deficit = 44 mg/L – Absolute humidity, or when expressed as percent: Humidity deficit(mg/L) / 44 mg/L x 100
Example:
An intubated patient attached to a T-piece is inspiring air from a nebulizer that contains 18 mg H2O per liter of air. What
is this patient’s humidity deficit?
44 mg/L – 18 mg/L = 26 mg/L
As a percentage: 26 mg/L / 44mg/L x 100 = 59%

- Gas being delivered to a patient with an ET tube or tracheostomy tube that contains less than 44 mg H2O per liter of gas, or a water vapor
pressure of less than 47 mmHg tends to dry secretions, making them thicker and more difficult to mobilize.
 Efficiency of Humidifiers
Depends on three important factors:

1. Duration of contact between the gas and water (Longer duration results in increased humidity).

a. The higher the flow rate used, the less time of contact between the gas and water, and therefore the
lower the humidity output.
b. The lower the water level in the jar, the less time of contact between the gas and water, and therefore
the lower the humidity output.

2. Surface area of gas and water contact (Greater surface area results in increased humidity).

3. Temperature of the gas and water (Higher temperature results in increased humidity).
 Pass-over humidifier (nonheated humidifier)
• Gas simply passes over the surface of the water, picking up moisture and delivering it to the patient.
• Produces low humidification.
• Provides a body humidity of approximately 25%.

Bubble humidifier (nonheated humidifier)

The most common type of humidifier used with low-flow oxygen delivery devices with flows of more than 4 L/min.
O2 entering the humidifier travels through a tube under the surface of the water and exits through a diffuser at the
lower end of the tube.
Provides a body humidity of 35% to 40%.
RUSALSHIDADISSE
 Wick humidifier (heated humidifier)

• Gas from the flowmeter or ventilator enters the humidifier and is exposed to the wick (made of cloth, sponge,
or paper), which is partially under the surface of the water.

• As gas passes the wick, it absorbs water that is delivered to the patient.

• Because the water bath or the gas is heated, a body humidity approaching 100% is delivered to the patient.
This method is ideal for patients with artificial airways and for those who receive mechanical ventilation.

Important Points Concerning Humidifiers

1. Most nonheated humidifiers have a pressure pop-off valve set at 2 psi.

After the device is set up, the tubing of the oxygen delivery device (e.g., cannula, mask) should be kinked to
obstruct flow. If the pop-off sounds, there are no leaks. If no sound is heard, all connections, as well as the
humidifier top, should be tightened.

2. Water levels of all humidifiers should be maintained at the levels marked on the humidifier jar to
ensure maximum humidity output.

3. Condensation occurs in the tubing of heated humidifiers. This water should be discarded in a trash

container or basin and should never be put back into the humidifier.
 Important Points Concerning Humidifiers
4. The temperature of inspired gas should be monitored continuously with an in-line thermometer when
heated humidifiers are used. The thermometer should be as close to the patient’s airway as possible.

5. Warm, moist areas, such as heated humidifiers, are a breeding ground for microorganisms (especially
Pseudomonas species). The humidifier should be replaced every 24 hours.

Humidifier particles are too small to carry the bacteria probably will not be delivered to the patient.

Nebulizers larger water particles produced are a more likely source of nosocomial infections and they
are able to carry the bacteria to the patient.

Heat Moisture Exchanger (HME)

- This device is placed in line between the patient’s ET tube and the ventilator adapter of the ventilator circuit.

- As the patient exhales, gas at body humidity and body temperature enters the heat moisture exchanger (HME), which
heats the hygroscopic filter (made of felt, plastic foam, or cellulose sponge) and condenses water into it. During the
next inspiration, gas passes through the HME and is warmed and humidified.
HEATMOISTUREEXCHANGER(HME)
- Under ideal conditions, the HME can produce 70% to 90% body
Hygroscopicmaterial
humidity. Patient's
alrway

- After an HME has been used on a ventilator patient for several

hours, the water absorbed by the HME can result in increased
resistance to flow, causing increased work of breathing, especially
for patients with underlying lung disease.
 Heat Moisture Exchanger (HME)
Another type of HME is the active HME. In addition to the hygroscopic properties of the device, humidity
and heat are added to the inspired gas, resulting in 100% humidity at body temperature being delivered.

If the patient’s secretions begin to thicken while an HME is being used, the HME should be replaced with a
conventional heated humidifier.

The HME may be used for temporary humidification during patient transport or during long-term
humidification for ventilator-dependent patients. If ventilatory pressure begins to increase, check for water
or secretions in the HME, and if there are obstructions, change to a new HME. If secretions are causing
obstruction, a conventional heated humidifier should be used.

- An HME is not recommended for use on a mechanically ventilated infant because it adds up to 90 mL of
mechanical dead space, exceedingly the VT of the infant.
Also, an infant is intubated with an uncuffed ET tube, and therefore some of the exhaled air leaks around the
tube and bypasses the HME. This reduces the amount of heat and moisture being absorbed.

Quiz
 AEROSOL THERAPY
Aerosol is defined as a suspension of water in particulate form (or a mist) in gas. Nebulizers produce aerosolized gas.

Clinical Uses for Aerosol Therapy

1. Laryngotracheobronchitis (LTB).
2. To administer medications (via handheld nebulizer [HHN] or ultrasonic nebulizer [USN]).
3. To hydrate the airway of a tracheostomy patient.
4. To induce a cough for sputum collection.
Hazards of Aerosol Therapy
1. Bronchospasm
2. Overhydration.
3. Overheating of inspired gas.
4. Tubing condensation draining into the airway.
5. Delivery of contaminated aerosol to the patient.

Characteristics of Aerosol Particles

1. The ideal particle size for therapeutic use in respiratory care is 1.0 to 5.0 µm.
2. Numerous factors affect the penetration and deposition of aerosol particles:
a. Gravitational sedimentation: The larger a particle is, the more effect gravity has on it and the sooner it will deposit.
b. Brownian movement: Affects particles of 0.1 µm or smaller in size.
c. Inertial impaction: larger particles have greater inertia, which keeps them moving in a straight line. Because they
cannot make directional changes in the airway.
d. Hygroscopic properties: Aerosol particles are hygroscopic (retain moisture). As they travel down the airway, they
may increase in size as they retain moisture, which may alter the time at which they deposit.
e. Ventilatory pattern: To obtain optimal particle penetration, the patient should be instructed to take
slow, moderately deep breaths with a 2- to 3-second breath hold at the end inspiration.
InertialImpaction

Sedimentation

Diffusion
 01 Pneumatic nebulizers

Jet nebulizer
Aerosol particles are produced when gas from the flowmeter passes through a small orifice (jet), resulting in
a drop in pressure that draws water up the capillary tube into the gas stream and then to a baffle that breaks
the water into fine aerosol particles.

Mechanical nebulizers produce about 50% of their particles in

the 0.5- to 3.0- µm size range.
 Small-volume nebulizer
Used as a handheld nebulizer or as a nebulizer on a ventilator or intermittent positive pressure breathing
(IPPB) circuit to deliver medications.
-Usually holds 3 to 6 mL of liquid medications.

Metered-dose inhaler (MDI)

This device delivers medication in aerosol form by squeezing the vial (in which the medication is stored)
upward into the delivery port. This activates a small valve that allows the pressurized gas to nebulize the
medication and deliver it to the patient.

The particle size produced varies from 2 to 40 um.

Only about 10% of the dose actually reaches the
lower respiratory tract.
The patient must be instructed thoroughly and
correctly on the proper use of the MDI to ensure
optimal aerosol particle penetration.
 Metered-dose inhaler (MDI)
The following points should be emphasized in teaching the patient proper use of the MDI:

(1) Do not place your lips around the delivery port. Instead, keep your mouth opened wide so that the teeth and
lips do not obstruct the flow of aerosol.

(2) Hold the MDI about 1 inch from the mouth, with the delivery port opening directed inside the mouth.

(3) Inhale as slowly and as deeply as possible. The MDI should be activated just after you start inhaling.

(4) Depending on the prescription, two or three aerosol doses (puffs) may be taken while waiting 30 s to 1 min
between puffs.

(5) Hold your breath at peak inspiration for 5 to 10 s for optimal aerosol penetration.

Metered-dose inhaler (MDI)

MDIs are also used for ventilator-dependent patients:

the device is placed directly into the inspiratory limb
of the circuit, and the respiratory care practitioner
activates it. Ideally, the aerosol should be delivered
during a sigh breath with an inspiratory hold.

Spacers and holding chambers, which are extensions placed on the outlet of the MDI, are effective in minimizing
aerosol loss and increasing the evaporation of the propellant. This increases the stability of the aerosol and results
in deeper penetration of the particles.
 02 Electric nebulizers

Ultrasonic nebulizer
A piezoelectric transducer located in the bottom of the couplant chamber of the unit is electrically charged and produces high-
frequency vibrations. These vibrations are focused on the bottom of the medication cup that sits in the couplant chamber. The
vibrations break the medications in the cup into small particles, which are delivered to the patient.

The frequency (which determines the particle size) of the electric energy supplied to the transducer is approximately
1.35 MHz. Particle size cannot be adjusted by the user.

The couplant chamber contains tap water to help absorb mechanical heat and
to act as a transfer medium for the sound waves to the medication cup.
 Hazards of ultrasonic therapy
(1) Overhydration
(2) Bronchospasm
(3) Sudden mobilization of secretions
(4) Electrical hazard
(5) Water collection in the tubing
(6) Changes in drug dosage caused by the drug reconcentrating as a result of the solvent in the medication cup,
leading to an increasingly stronger dose as the treatment continues.

Vibrating mesh nebulizer

The VM nebulizer features a mesh plate (mesh cap) that has more than 1000 tiny laser-drilled holes.

An attached or separate power supply provides electricity to the mesh plate, causing it to vibrate at a
frequency of 130 kHz (or one tenth that of the ultrasonic nebulizer; therefore, less energy is used, and less
heat is produced). As the plate begins to vibrate, it acts like an electronic micropump.

The plate actively pumps the medication through the holes, thus producing a dense aerosol at extremely low
flow rates. Due to the efficiency of VM nebulizers, residual drug volumes in the nebulizer are reduced,
which may lower the cost when expensive medications are being administered.
The particle size produced
is 2 to 3 um and has a
much shorter delivery time
than particles produced by
pneumatic small-volume
nebulizers.
 Important Points Concerning Nebulizers:
1. Of all respiratory equipment, heated nebulizers are the source of the greatest delivery of contaminated moisture
to the patient; Pseudomonas species are the most common contaminant. These nebulizers should be replaced every
12 to 24 h.
2. Make sure that jets and capillary tubes are clear of debris or buildup of minerals by cleaning after each use. If the
nebulizer is not producing adequate mist, a clogged capillary tube or jet may be the cause.
3. Keep water drained out of the aerosol tubing to avoid increasing the percentage of O2 delivered to the patient.
Water in the tubing obstructs gas flow, resulting in back pressure into the nebulizer. As pressure increases in the
nebulizer, less air is entrained in the entrainment port; therefore, delivered FiO2 increases, total flow to the patient
decreases, and less aerosol is delivered.
4. Keep the water level at the appropriate markings on the nebulizer to ensure optimal aerosol output.

Quiz
 02
MANUAL
RESUSCITATION
TECHNIQUES/EMERGE
NCY

MANUAL RESUSCITATORS
Manual resuscitation is a form of artificial respiration that uses a breathing bag
(manual resuscitator) to assist patients with breathing.

• Uses of Manual Resuscitators:

1. Manual ventilation.
2. Hyperinflation of lungs before tracheal suctioning.
3. During transport of patient who requires artificial ventilation.
 MANUAL RESUSCITATORS
• Design of Resuscitators:
- The nonrebreathing vale have exhalation valve and ports, to prevent the rebreathing of exhaled air.
- Most resuscitators use self-inflating bags. Some resuscitators are flow-inflating bags, so they cannot operate
without oxygen flow.
- A reservoir attachment should be connected to the bag intake valve to ensure higher FiO2 level (100%). If a
reservoir is not attached, the delivered FiO2 is only 40% to 50%.
- Some resuscitator bags have pressure-relief devices that open to the atmosphere at a pressure of 40 cm H2O,
so that excessive pressures are not delivered to the patient’s lungs.
➢ To achieve the highest delivered O2 levels possible, use the following criteria:
a. reservoir.
b. High flow rate (10 to 15 L/min).
c. Use the longest possible bag refill time (meaning a slower ventilation rate). Allow the bag to fully refill
before the next breath.

What does a fast Ventilation rate cause?

- Decreases of the percentage of delivered O2.
- Decreases cardiac output.
- Decreases blood flow to the brain if the patient is hyperventilated.
- Increases the risk for aspiration.
- Increases affinity of hemoglobin for O2, thereby reducing tissue oxygenation.

It is recommended to deliver one breath every 5 to 6 seconds for respiratory arrest.

Note: What if little or no resistance is met, and the chest does not rise adequately?
suspect a leak around the exhalation valve, O2 intake valve, or ET tube cuff, or a poorly fitting mask.
 Mouth-to-Valve Mask Ventilation

This method of ventilation provides personal protection when ventilating a

patient and is preferred over mouth-to-mouth ventilation.

PHARMACOLOGIC INTERVENTION
• Routes of Administration DURING CPR
1. A central venous line (central line) is the ideal route, if available.
2. A peripheral IV line is the best route when a central venous line is not available.
3. Intraosseous (IO) infusion may be used when IV cannulation is unsuccessful or is taking too long.
4. ET tube: drugs may be instilled directly into the tracheobronchial tree via the ET tube for rapid absorption.
To recall CPR drugs more easily, remember the acronym NAVEL.
N: Naloxone hydrochloride (reverses the effect of a narcotic overdose)
A: Atropine sulfate
V: Vasopressin
E: Epinephrine
L: Lidocaine
 PHARMACOLOGIC INTERVENTION
DURING CPR
Keep in mind that ETT route is not preferred. Recent studies indicate that giving resuscitation drugs through
the ET tube results in lower blood concentrations than if the same dose is given IV. The recommended doses
of drugs that are administered endotracheally are generally two to three times the IV dose, but the optimal
endotracheal drug dose of most drugs is not known.

5. Intracardiac: Epinephrine is the only drug that may be injected directly into the heart, but only when the ET
tube or IV route is not available or has failed to elicit a response.

Drugs Commonly Administered During CPR

 Drugs Commonly Administered During CPR

CARDIOVERSION
• Cardioversion is a synchronized current of electricity delivered to the heart during ventricular
depolarization (QRS complex).
• Cardioversion is used to terminate the following arrhythmias:
1. Atrial flutter.
2. Atrial fibrillation.
3. Ventricular tachycardia.
4. Paroxysmal supraventricular tachycardia.
5. Ventricular fibrillation.
• Cardioversion delivers a lower energy level than does defibrillation.
- Normal levels for cardioversion are a charge of 50 to 100 J to restore normal cardiac rhythm in adults.
- 0.2 to 1.0 J/kg in infants and children.
- For atrial fibrillation, 120 to 200 J is used.
 AUTOMATED EXTERNAL
DEFIBRILLATION (AED)
• AEDs are devices that provide early defibrillation in a witnessed cardiac arrest,
which is generally caused by ventricular fibrillation.
• Placement of pads:
1- One pad is placed directly below the right clavicle (collarbone), and the other is
placed to the side of the left nipple with the top of the pad a few inches below the
armpit.
2- Alternative pad placement is one just below the left nipple and next to the sternum
and the other just below the left shoulder blade on the back.

• Troubleshooting messages may occur on the AED and direct the user through corrective
actions.

1. Problem with the pads: Make sure the pads are completely adhered to the skin. If they are loose, a poor connection
is present, and the shock won’t be effective. Make sure the cable connector to the pad is firmly connected to the AED.
2. Make sure the patient’s chest is dry. If it is wet, the pads may not stick adequately.
3. If chest hair is preventing the pads from sticking well, the chest should be shaved in that area. It’s a good idea to have a
razor with the AED.
4. A message may indicate that analysis has been interrupted because of movement. Stop all sources of movement, such as
chest compressions or rescue breathing.
5. A message may indicate that the battery needs to be replaced. Only a limited number of shocks may be available until the
battery needs to be replaced.
6. If the patient has a surgically implanted device in the chest, such as a pacemaker, place the pads at least an inch away
from the device.
7. Medication patches should be removed if they are located where a pad is to be attached. Wipe away any residue left on
the skin from the patch and then apply the AED pad.
 TRANSPORTING THE CRITICALLY ILL
PATIENT
Patients may be transported by either land or air.
- The respiratory therapist should hold the ET tube with one hand and the bag with the other and stand at the head of the
patient. This better stabilizes the tube and helps avoid accidental extubation until the tube is secured.
- Sudden changes in speed or direction may cause a drop in the patient’s blood pressure.
- Special attention must be given to monitoring lines.
- Patients should be adequately sedated to help prevent anxiety and allow safer transport.
- During transport in an unpressurized aircraft, rapid increases in altitude result in decreased atmospheric pressure and PO2.
This may be managed by increasing delivered O2 concentrations.
- Higher altitudes (lower atmospheric pressure) may increase the size of an untreated pneumothorax and increase
- ET tube cuff pressure, which may decrease capillary perfusion to the trachea.
- Heated humidity or aerosol for ventilators or masks during transport is not necessary for such short-term use.

• Respiratory Care Equipment Needed During Transport.

1. O2 system (tanks or liquid)
2. Portable suction machine and catheters
3. Portable ventilator
4. Portable ECG unit
5. Arterial pressure monitor
6. Pulse oximeter
7. Intubation equipment
8. Manual resuscitator
 Quiz

Thanks
Does anyone have any questions?